Every finding on record at Country Drive Post Acute

Based on interview and record review, the facility failed to provide notice of rights and services prior to or upon admission for four of five sampled residents (Resident 1, 2, 3, and 4), when admission agreements were either delayed or not provided at all.This failure had the potential to result in unnecessary emotional stress, diminished autonomy in making healthcare choices and violation of resident rights.During an interview on 2/23/26 at 11:41 a.m. with Admissions Director (AD), AD stated the admission agreement is very important as it covers information about resident rights, advanced directives, facility and Ombudsman information, arbitration agreement and details on what residents should expect. AD stated the resident or the resident's decision-maker should sign the admission agreement within 72 hours of admission.1.During a review of Resident 1's admission Record (AR) dated 2/20/26, the AR indicated Resident 1 was admitted to the facility on [DATE]. The AR also indicated Resident Representative (RR) 1 as Resident 1's Emergency Contact and that Resident 1 was self-responsible (able to make decisions for themselves). Resident 1 was transferred to the hospital after a medical emergency on 10/10/25.During a review of the State-specific admission Agreement (SAA) titled California Standard Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, the SAA indicated it was signed by RR 1 on 10/2/25, eight days after Resident 1's admission.2. During a review of Resident 2's AR dated 2/23/26, the AR indicated Resident 2 was admitted to the facility on [DATE]. The AR indicated Resident 2 was self-responsible but listed RR 2 as emergency contact. The AR also indicated Resident 2 was discharged home on [DATE].During a concurrent interview and review of the clinical records on 2/23/26 at 12:33 p.m. with Assistant Director of Nursing (ADON), ADON stated there was no signed admission agreement for Resident 2 in the clinical records.3. During a review of Resident 3's AR dated 2/20/26, the AR indicated Resident 3 was admitted to the facility on [DATE]. The AR indicated Resident 3 was self-responsible and listed RR 3 as the emergency contact, Resident 3 was discharged home on [DATE].During a telephone interview on 2/18/26 at 1 p.m. with RR 4, RR 4 stated the admission agreement was given to RR 3 only on the day Resident 3 was discharged . RR 4 also stated Resident 3 and family were unaware of the care and services were provided while at the facility.During a review of Resident 3's SAA, the SAA indicated Resident 3 was issued the admission agreement on 12/5/25, the day Resident 3 was going home.4.During a review of Resident 4's AR dated 2/20/26, the AR indicated Resident 4 was admitted to the facility on [DATE]. The AR indicated Resident 4 was self-responsible.During a review of Resident 4's SAA, the SAA indicated Resident 4 signed the admission agreement on 1/2/26, more than one month after Resident 4 was admitted .During a review of the facility's policy and procedure (P&P) titled admission Agreement last revised December 2025, the P&P indicated that each resident must have an admission agreement, signed and dated by the resident or resident representative at the time of admission and filed in the resident's clinical record.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2) received advance notice of a roommate change, when Resident 6 was moved into Resident 2's room. This failure had the potential to result in avoidable psychosocial distress.During a review of Resident 2's admission Record (AR) dated 2/23/26, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis that included encounter for removal of internal fixation device (a medical procedure involving the removal of hardware, such as screws, plates, or rods, that were previously implanted to stabilize a bone or joint), anxiety disorder (a mental health condition characterized by excessive worry, nervousness, or fear that can interfere with daily activities), and depression (a mood disorder marked by persistent feelings of sadness, hopelessness, and loss of interest in activities).During a review of Resident 2's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 11/11/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 13. A BIMS score of 13-15 is an indication of intact cognitive status.During a concurrent interview and record review on 2/20/26 at 3:54 p.m. with Assistant Director of Nursing (ADON), ADON stated the facility does not provide a written notice when a resident acquires a new roommate. ADON stated a written notice is only provided to residents when they are moving to a new room.During a review of the facility's policy and procedure (P&P) titled Room or Roommate Change, effective date 6/27/22, the P&P indicated that residents or their representatives will receive timely advance notice before a room or roommate change. This notice can be given verbally, in writing, or both.During a concurrent interview and record review on 2/23/26 at 12:14 p.m. with ADON, facility's daily census from 11/7/25 to 11/23/25 was reviewed. ADON stated Resident 2 was admitted on [DATE] and shared a room with Resident 6, until 11/12/25 when Resident 6 was transferred to the hospital. ADON stated, on 11/17/25, Resident 2 received a new roommate without advanced written notice, only verbal notice, which was not documented in the clinical record.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 5) had their personal funds safeguarded when Resident 5's wallet containing $140, which had been entrusted to the facility's Social Services Director (SSD), was not secured in accordance with facility procedures. This failure resulted in Resident 5's $140 going missing, which had the potential for psychosocial outcomes including anxiety, distress, and reduced trust in the facility's ability to safeguard belongings.During a review of Resident 5's admission Record (AR) dated 2/23/26, the AR indicated Resident 5 was admitted to the facility in July 2025 with diagnoses that included diabetes mellitus (a chronic condition characterized by high levels of sugar in the blood due to the body's inability to produce or use insulin effectively), benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland that can cause urinary problems in men), and chronic gout (a long-term form of arthritis caused by the buildup of uric acid crystals in the joints, leading to pain and inflammation). The AR indicated Resident 5 was self-responsible.During a review of Resident 5's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 11/25/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 13. A score of 13-15 is an indication of intact cognitive status.During a concurrent interview and record review on 2/23/26 at 11:03 a.m. with Administrator (ADM), ADM stated, on 11/21/25, Resident 5 handed over a wallet with $180 cash to SSD for safekeeping. The SSD placed the wallet in an unlocked drawer in the SSD office. In December 2025, Resident 5's family requested $140 from Resident 5's money but found only $40 remaining. ADM stated SSD no longer works at the facility.During a review of Resident 5's Social Services Progress Notes from 10/15/25 to 12/26/25, the progress notes did not indicate Resident 5 was informed about the missing $140. SSD had discussed it with Resident 5's family but not with Resident 5.During an interview on 2/23/26 at 11:22 a.m. with Resident 5, Resident 5 stated the facility still had the wallet, stated a man had visited his room and provided a number to call to regarding the missing money.During a review of the facility's policy and procedure (P&P) titled Management of Residents' Personal Funds last revised March 2021, the P&P indicated if a resident chooses to have the facility manage his personal funds, a written authorization from the resident or the resident representative is required and documented in the resident's clinical record. The facility acts as a fiduciary, holding, safeguarding, managing and accounting for the personal funds.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 3) received a summary of the baseline care plan, when neither Resident 3 nor Resident 3's Representative (RR 3) were provided with the required summary.This failure had the potential to place Resident 3 at risk for unmet needs, inconsistent care and adverse health outcomes.During a review of Resident 3's AR dated 2/20/26, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included fractured left pubis (a break in the left side of the pubic bone, which is part of the pelvis), sacrum (the triangular bone at the base of the spine), and upper end of left humerus (a break near the top of the left upper arm bone), dementia (a general term for a decline in mental ability severe enough to interfere with daily life, often involving memory loss and impaired judgment), difficulty in walking, and delirium (a sudden and severe confusion due to rapid changes in brain function, often temporary but serious). The AR indicated Resident 3 was self-responsible (able to make decisions for themselves) and listed RR 3 as the emergency contact.During a concurrent interview and record review on 2/20/26 at 11:38 a.m. with Assistant Director of Nursing (ADON), Resident 3's Interdisciplinary Care Conference (ICC) dated 11/21/25 was reviewed. ADON stated she was not sure whether a summary of the baseline care plan was provided to Resident 3 or RR 3, as the notes did not indicate this. ADON also stated a representative of Resident 3 participated in the care conference, but the record did not indicate who it was. The ICC indicated attendees that included only seven facility representatives, and the section on whether the care plan summary copy was provided was left blank.During a telephone interview on 2/18/26 at 1 p.m. with RR 4, RR 4 stated RR3 received the admission agreement only on the day Resident 3 was to be discharged . RR 4 also stated Resident 3 and family were unaware of the care and services to be provided at the facility. During a review of the facility's policy and procedure titled Care Plan-Baseline effective 8/25/21, the P&P indicated the baseline care plan includes the instructions for effective, person-centered care of the resident and be developed and implemented by the Interdisciplinary Team (IDT, a group composed of staff representing different departments of the facility) for each resident. The P&P did not indicate when or how to provide a summary of the baseline care plan to the resident or their representative.

Based on observations, interviews, and record reviews, the facility failed to ensure consistent implementation and proper use of personal protective equipment (PPE) when staff members were not wearing the N95 respirator (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles), or N95 respirator was worn improperly. Visitors were not aware of the recommendation to use face mask when visiting their family members. These failures had the potential to affect the health and safety of the residents and visitors due to exposure to respiratory illness.During an observation on 08/08/25 at 2:30 p.m., in the facility's reception area, Licensed Vocational Nurse (LVN) 1 and Housekeeper (HS) 1 were not wearing face masks. Receptionist 1 was in the reception area, and her face mask was pulled down and tucked under her chin.During an interview on 08/08/25 at 2:35 p.m., with the Administrator (ADM), ADM stated the Infection Preventionist (IP) was out on leave, and the Assistant Director of Nursing was covering. ADM stated before going on leave, IP communicated with local public health that there was a Covid-19 (infectious disease caused by Corona Virus with symptoms that can feel like cold, flu, or pneumonia. COVID-19 spreads when an infected person breathes out droplets and very small particles that contain the virus. Other people can breathe in these droplets and particles, or these droplets and particles can land on others' eyes, nose, or mouth. In some circumstances, these droplets may contaminate the surfaces they touch. Anyone infected with Covid-19 can spread it, even if they do not have any symptoms.) outbreak in the facility. During a concurrent observation and interview on 08/08/25 at 2:48 p.m., with Assistant Director of Nursing/Infection Preventionist (ADON/IP), ADON/IP identified LVN 1, and HS 1 were not wearing face masks, and Receptionist 1's face mask was pulled down and tucked under her chin. During a concurrent observation and interview on 08/08/25 at 2:54 p.m., in the hallway with Certified Nursing Assistant (CNA) 1, CNA 1 had a N95 respirator worn over a face mask. CNA 1's N95 respirator was worn sideways with the two straps worn behind their ears. CNA 1 stated she needed to wear the N95 respirator for protection, but was unable to describe how to properly wear the N95 respirator. During a concurrent observation and interview on 08/08/25 at 03:09 p.m., in the hallway with CNA 2, CNA 2 had an N95 respirator worn over a face mask. CNA 2's N95 respirator double straps were worn close to the top of her head. CNA 2 was not able to describe how to properly wear the N95 respirator, CNA 2 stated she needed to wear N95 respirator for protection.During a concurrent observation and interview on 08/08/25 at 03:12 p.m., with Resident 1 and Responsible Party (RP) 1, RP 1 was pushing Resident 1's wheelchair and were heading to Resident 1's room. RP 1 and Resident 1 were both not wearing face masks. RP 1 stated when she entered the facility she was not offered or asked to wear a face mask.During a concurrent observation and interview on 08/08/25 at 03:14 p.m., in the nursing station with Registered Nurse (RN) 1, RN 1 was not wearing any face covering. RN 1 stated she had just started her shift and was looking for a face mask. RN 1 states she doesn't know if she should be wearing a face mask before going on the floor.During a concurrent observation and interview on 08/08/25 at 03:18 p.m., in Resident 2's room with Responsible Party (RP) 2 in the room. RP 2 was not wearing a face mask, and RP 2 stated he was not offered or asked to wear a face mask when he entered the facility.During a concurrent observation and interview on 08/08/25 at 05:16 p.m., with ADON/IP, ADON/IP stated N95 respirator should not be worn over a face mask. ADON/IP stated that after putting on the N95 respirator, the staff had to do a seal check. ADON/IP stated the licensed nurse should be wearing an N95 respirator before going to the floor.During an interview on 08/08/25 at 05:31 p.m., with ADON/IP, ADON/IP stated that IP had mask guidelines from county public health. ADON/IP stated that all licensed nurse and CNA would need to wear a N95 respirator. Kitchen staff also needs to wear N95 respirator during food preparation. Housekeeping staff need to wear face masks and change to N95 respirators when going to the resident's room in isolation. During a review of the facility's policy and procedures (P&P) titled, Covid-19 Management, undated, the P&P indicated, 2. Infection Prevention and Control a. Source control. II. Staff. ii. When Covid-19 hospitalization levels are high or when in an outbreak, all staff should wear a surgical/procedure mask or higher (N95 respirator) for source control when providing resident care, Working with a resident in-person, or in resident care areas in the facility. III. Visitors i. Visitors are strongly recommended to wear a well-fitting mask when: the Covid-19 hospitalization levels are high. The facility is in an outbreak or visiting residents at high risk of illness (immunocompromised).

Based on interview, and record review the facility failed to ensure a minimum of 3.5 Direct Care Service Hours Per Patient Day (DHPPD - refers to the minimum number of direct care service hours a facility is required to provide to each resident per day) and a minimuim of 2.4 Certified Nursing Assistant (CNA) DHPPD on ten weekend days. This failure had the potential to result insufficient nursing staff and inadequate nursing care for the facility residents. Findings: During an interview on 4/23/25, at 9:53 a.m., with Staff Developer Assistant (SDA), SDA stated they completed the daily staffing schedule and were required to staff for a minimum of 3.5 DHPPD and 2.4 CNA DHPPD. During an interview on 4/23/25, at 10:28 a.m., with Director of Staff Development (DSD), DSD stated staffing effected patient care, and patient care was a top priority. During a concurrent interview and record review on 4/23/25, at 11:11 a.m. with Payroll Coordinator (PC), the Facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) reports between 5/1/24 through 6/30/24 were reviewed. PC stated the following Census and Direct Care Service Hours Per Patient Day (DHPPD) reports indicated low DHPPD and low CNA DHPPD on the following days: 5/1/24 DHPPD was 3.49 and CNA DHPPD was 2.23 5/30/24 DHPPD was 3.42 and CNA DHPPD was 2.19 6/1/24 DHPPD was 3.18 and CNA DHPPD was 1.84 6/2/24 DHPPD was 3.07 and CNA DHPPD was 1.86 6/9/24 DHPPD was 3.20 and CNA DHPPD was 2.04 6/15/24 DHPPD was 3.38 and CNA DHPPD was 1.99 6/16/24 DHPPD was 3.12 and CNA DHPPD was 1.99 6/22/24 DHPPD was 3.11 and CNA DHPPD was 1.93 6/23/24 DHPPD was 3.27 and CNA DHPPD was 2.07 6/30/24 DHPPD was 3.18 and CNA DHPPD was 1.79 During a review of the facility's Staffing Waiver dated 6/20/23, the Waiver indicated, The facility shall provide no less than 3.5 direct care service hours per patient day.

Based on observation, interview, and record review, the facility failed to ensure that prescription medications were properly labeled and stored as evidenced by: 1. This failure was identified during the inspection of one of three medication carts and had the potential to result in medication errors, including the risk of incorrect administration, diversion, or harm to residents receiving medications from that cart when multiple medications were found without a prescription label. 2. The facility stored multiple medications in a medication refrigerator that was operating at a temperature of 14°F, significantly below the required refrigeration range of 36°F to 46°F. This deficiency created the potential for insulin degradation, rendering the medication ineffective or unsafe for resident use. The failure to maintain proper storage conditions compromised the integrity of medications administered to multiple residents. Findings: 1. During an observation on 4/21/25, at approximately 2:00 PM, it was observed alongside Registered Nurse (RN 1). During the inspection, it was observed multiple medications within the cart drawers that lacked prescription labels and any identifying resident information. Among the items found was a Humalog (insulin lispro) KwikPen, which did not have a prescription label or any indication of which resident it was intended for. Additionally, a pink circular pill organizer containing a mixture of various oral tablets-differing in size, shape, and color-was present. The only marking on this organizer was the handwritten number 157 in black ink; it lacked any resident name, prescription label, or clear medication identifiers. Also present was an Albuterol Sulfate Inhaler that displayed only the product name and usage directions, but did not include any labeling from a pharmacy or the name of the resident for whom it was prescribed. These medications were not separated from other facility-stocked medications and were stored in a manner that failed to prevent potential medication administration errors. The lack of segregation and secure storage increased the likelihood that medications could be given to the wrong resident or accessed inappropriately, thereby compromising resident safety. During an interview on 4/21/25 at 2:00 PM, RN 1 acknowledged that the medications were brought in by a resident and admitted that they had not been properly labeled. She stated, They were brought in by the resident. I know they're supposed to be labeled. They should have been. RN 1 confirmed that she was aware these items were stored in the cart and further acknowledged that they should not have been in use or available for administration without proper pharmacy labeling and verification. This deficient practice indicates a systemic failure to adhere to established medication management policies and compromises the facility's obligation to ensure safe and accurate pharmaceutical care for all residents. 2. During an observation 4/22/25 at 1:50 PM, the surveyor observed the medication refrigerator located in the facility's medication storage area. The thermometer inside the unit displayed a temperature of 14°F, indicating that the contents of the refrigerator were exposed to freezing conditions. Multiple insulin vials and pens were observed inside the refrigerator, all of which were clearly labeled with manufacturer stickers stating, Refrigerate until used. Once in use, store at room temperature. According to the manufacturers and current pharmaceutical standards, insulin must never be frozen, as freezing compromises its molecular structure and can result in the loss of therapeutic efficacy and safety. During an interview 4/22/25 at 1:50 PM, the facility's nursing supervisor 1 acknowledged the issue. When asked about the temperature reading, she stated, I wasn't aware it was out of range. That's not appropriate. We'll start monitoring and have maintenance look at it. This admission confirmed that staff had not previously identified or addressed the unsafe storage condition. There was no indication that the affected insulin had been evaluated for safety or removed from circulation. The facility's failure to ensure appropriate storage of refrigerated medications placed residents at risk for receiving medications that may have been rendered ineffective or harmful due to improper handling.

Based on observation, interview, and record review, the facility failed to ensure for one out of 29 sampled residents (Resident 220), an ongoing and consistent collaboration with dialysis center for Resident 220 was established. Resident 220's dialysis communication binder did not contain the current physicians orders, no follow up for recommended medication to be discontinued, and facility staff was noting inconsistent assessment on the dialysis access site. These failures had the potential to affect Resident 220's health and safety due to lack of coordination with dialysis center. Findings: During a review of facility's admission Record indicated Resident 220 was admitted on [DATE], with diagnoses that included severe kidney disease and hypertensive emergency. Resident 220's physician orders indicated Clonidine (medication used to treat high blood pressure) transdermal patch weekly 0.3 milligram (mg)/24 hour. Apply two patches transdermally one time a day every seven days related to essential hypertension. Resident 220's Minimum Data Set (MDS - resident assessment tool) dated 04/15/2025, indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 13, (BIMS score of 13 - 15, cognitively intact). During a review of Resident 220's Dialysis Communication Record (DCR), dated 4/14/25 indicated Resident 220's dialysis access site was located on L-perm cath [left chest permacatheter - catheter used for short-term dialysis treatment. The catheter is placed inside a blood vessel in your neck or just under your collarbone and through the right side of the heart]. The dialysis center noted Can you please give us her home med [medication] list? Section Post Hemodialysis Assessment indicated Resident 220's access site was RUA [right upper arm], and the access site had bruit (swooshing sound of a dialysis fistula caused by the high-pressure flow of blood through the fistula), and thrill (vibration caused by blood flowing through the fistula). Resident 220 would not have bruit and thrill since her dialysis access site was a permacatheter on her left chest. Resident 220's DCR dated 4/18/25 Post Hemodialysis Assessment dialysis access site was RUA, with bruit and thrill present. Further, the DCR indicated a post dialysis notes from the dialysis center per nephrologist Dr . discontinue Clonidine patches. During a review of Resident 220 medication administration record (MAR) for the month of April 2025 indicated Resident 220 attended dialysis three times a week on Monday, Wednesday, and Friday. Resident 220's MAR indicated Clonidine Transdermal patch weekly 0.3 mg/24 HR, apply 2 patches transdermally one time a day every seven days. Clonidine 0.3 mg patches were applied on 4/19/25. During a concurrent observation and interview on 04/22/25 at 07:36 A.M., in Resident 220's room with Resident 220 lying down on her bed. Resident 220 stated she went to the dialysis center the previous afternoon. Resident 220 stated the dialysis center would like to have a list of her medications, because it was not in the communication binder. Resident 220 stated access site for her dialysis was on the left side of her chest. Resident 220 stated she had the Clonidine patches on her both sides of her upper back. During a concurrent interview and record review on 04/23/25 at 7:45 A.M., with Director of Staff Development (DSD), DSD stated the physicians order had to be in the dialysis communication binder. DSD reviewed Resident 220's dialysis binder and there was no copy of the medication list. DSD reviewed Resident 220's Resident 220's DCR dated 4/18/25, which indicated to discontinue Clonidine patches, and dialysis access site located at right upper arm with bruit and thrill. DSD stated that Resident 220's dialysis access site was on her left upper chest would not have bruit and thrill because she had permacatheter. DSD stated she would notify Resident 220 about the Clonidine patches. During a review of facility's policy and procedure titled Dialysis Care with effective date 08/25/2021, indicated I. Purpose. To provide dialysis care for residents in renal failure and those residents who require ongoing dialysis treatments III Procedure 4. Communication and Collaboration. a. The Nursing Staff, Dialysis Provider Staff, and the Attending Physician (Dialysis Staff) will collaborate on a regular basis concerning the resident's care as follows: i. Nursing staff will communicate the following information in writing to the Dialysis Staff: The resident's current vital signs. Any changes of condition specific to the resident with each treatment. ii. The dialysis Provider will communicate in writing to the facility any problems encountered while the resident was at the dialysis provider and any ongoing monitoring required. iii. Nursing Staff will keep the Attending Physician, the resident and the resident's family informed of any change in condition. iv. Nursing Staff may use the Hemodialysis communication record.

Based on observation, interview, and record review, the facility failed to provide activities for one resident of 23 sampled residents (Resident 266) based on assessment and care plan, preferences, and in a manner designed to meet the resident's needs. This failure placed Resident 266 at risk for isolation and boredom and may negatively impact his psychosocial well-being. Findings: A review of Resident 266's admission record indicated Resident 266 was admitted on [DATE] with diagnoses that included pneumonia, weakness, and difficulty in walking. During an observation on the intial tour, on 4/21/25 at 10:45 a.m., Resident 266 was lying in bed, awake, alert. Resident 266 had in his hands a plastic syringe used for his Gastrostomy tube (G Tube- A medical device inserted into the stomach to deliver food and liquids) and played with it. Resident 266 unable to talk when spoken to. No TV or music was playing in the room.When alerted, CNA 1 entered Resident 266's room and took the syringe from Resident 266 and placed it on his nightstand and picked the paper cover for the syringe from the floor by Resident 266's bed and trashed it. During an observation on 4/22/25 at 9:20 a.m. Resident 266 was lying in bed, awake alert. Resident's GT was connected to his stomach and GT feed was running via the GT pump. No TV or music was playing in the room. Resident 266 responded to greeting with a smile, but did not talk when spoken to. A review of the Minimum Data Set (MDS - an assessment tool used to direct care) Section C - Cognitive Patterns indicated Resident 266 with short- and long-term memory problem and Cognitive skills for Daily Decision Making indicated Modified independence - some difficulty in new situations only. During an interview on 4/22/25 at 12:26 p.m. with the Activity Director (AD), AD stated Resident 266 was not getting out of bed and they did in-room visits for him. AD could not state what activities they provided during room visits. AD stated she would go and check. The activity care plan for Resident 266 was requested from AD. AD did not return until around 2 p.m. During a review of Resident 266's electronic medical record on 4/22/25 at around 1:28 p.m. there was no activity care plan found on record. During a review of the MDS Section F, Preference for Customary Routine and Activities, F0800 Staff Assessment for Daily and Activity Preferences dated 3/31/25, indicated no resident's choice and preferences for Resident 266. During a concurrent interview and record review on 4/23/25 at 9:30 a.m. with AD, AD acknowledged there was no individualized activity assessment for Resident 266 because she left a message for the family/significant other regarding resident's preferences for activity. AD stated she did not follow up with them since 4/4/25 and just did yesterday 4/22/25. AD stated they have been doing in room visit for Resident 266 and they have the logs for visit and would provide them. She stated the logs were paper forms and not on the computer. AD stated they just anticipated what activities they would offer resident when they do room visit. She stated they were supposed to follow the plan and Resident 266 did not have a plan when he should have had one. AD stated the care plan was generated after the assessment was done on 4/22/25. AD stated the individual assessment needed to be done within five to seven days of resident's admission. AD stated it was important so that they assess and find out what residents like and don't like. During an interview on 4/23/25 at 9:54 a.m. with the Director of Nursing (DON), DON stated it was important they get an assessment so they can have a plan. She stated activity was important to know what the residents like, to get them engaged. During a review of the facility's policy and procedure (P&P) titled, Individual Activities and Room Visit program dated Revised 2018, the P&P indicated, Individual activities are provided for individuals who have conditions or situations that prevent them from participating in group activities, or who do not wish to do so .Individualized activities are offered reflective of the resident's activity interests, as identified in the Activity Assessment, .and the resident's Comprehensive Care Plan . During a review of the facility's policy and procedure (P&P) titled, Care Plan Comprehensive, dated 8/5/21 indicated, An individualized comprehensive care plan that incudes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident .The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS) .

Based on observation, interview, and record review, the facility failed to ensure accurate medication administration for 2 of 25 medications observed during a medication pass, resulting in a medication error rate of 8%, which exceeds the acceptable federal threshold of 5%. This failure created the potential for subtherapeutic treatment, adverse side effects, and inadequate symptom control for Resident 38. Findings: On 4/2/125, at approximately 1:16 PM, the surveyor conducted a medication administration observation with Registered Nurse (RN) 1. During this observation, RN 1 administered Lantus Insulin, 17 units subcutaneously (SC), and Novolog Insulin, 4 units SC, to Resident 38. During the administration of Novolog Insulin, the surveyor observed that RN 1 failed to follow proper technique by not holding the insulin pen in place for the full manufacturer-recommended time following injection. The needle was held in place for approximately 2 to 3 seconds before being withdrawn. According to manufacturer package insert, insulin pens must be held in place for at least 5 to 10 seconds to ensure full delivery of the medication and to prevent insulin leakage, which could lead to underdosing and ineffective glycemic control. Each instance of incorrect administration of a different insulin medication is counted as a separate medication error. Therefore, the incorrect technique affected both Lantus and Novolog administration and constitutes two medication errors during the single observation period. These errors contributed to a medication error rate of 8%-a rate which exceeds the maximum allowable error rate of 5% as defined by federal standards. During a follow-up interview conducted immediately after the observation on 4/2/125, at approximately 1:16 PM, RN 1 was asked about the technique used during insulin administration. She said she forgot and will do better next time.

Based on interview and record review, the facility failed to ensure for one out of three sampled residents (Resident 1), monitoring and interventions were in place to prevent development of pressure ulcer (skin and soft tissue injuries that develop due to prolonged pressure exerted over specific areas of the body). Resident 1 developed a pressure ulcer on posterior of the right lower leg where an immobilizer (a device used to support and stabilize the leg and knee) was applied. These failures resulted in a facility acquired, unstageable pressure ulcer (pressure ulcer known but not stageable due to coverage of wound bed by moist dead tissue and/or crusty, dry, and dead tissue), on the right lower leg that caused pain and extended Resident 1 ' s stay at the facility. Findings: During a review of facility ' s admission Record (AR) printed on [DATE], the AR indicated Resident 1 was admitted on [DATE], with diagnoses that included Periprosthetic Fracture Around Internal Prosthetic Right Hip Joint, (A broken bone around a hip replacement). Resident 1 ' s physician Order Recap Report for [DATE] indicated, right leg-knee immobilizer at all times, and non-weight bearing tight [right] leg. Resident 1 ' s Braden Scale for Predicting Pressure Sore Risk, (an assessment tool used evaluate a risk for developing pressure ulcer) dated [DATE] indicated a score of 13 (Moderate risk score 13 - 14). Resident 1 ' s Body Check dated [DATE], indicated there were no identified skin problem on Resident 1 ' s right leg. During a review of Resident 1 ' s clinical record titled Care Plan Report (CPR), initiated on [DATE], indicated Resident 1 Has higher risk of/potential for pressure ulcer development r/t [related to] Disease process. Planned interventions in the CPR included Assess/record/monitor wound healing (FREQ) [Frequency]. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress . Follow facility policies/protocols for the prevention/treatment of skin breakdown. Resident 1 ' s CPR did not identify and include interventions for Resident 1 ' s risk of skin breakdown on the right leg from the use of immobilizer. Resident 1 ' s CPR did not indicate a refusal of care for skin check underneath the right leg immobilizer. Further, Resident 1 ' s CPR was not updated when a pressure ulcer was identified on [DATE]. During a review of Resident 1 ' s Minimum Data Set (MDS - resident assessment tool) dated [DATE], the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident ' s cognitive status regarding attention, orientation, and ability to register and recall information) score of 10, (BIMS score of 08 - 12, moderate cognitive impairment). Resident 1 ' s MDS skin assessment, indicated Resident 1 was at risk developing pressure ulcers/injuries, and had no unhealed pressure ulcer/injuries. During a review of Resident 1 ' s clinical record titled Change in Condition Evaluation - V5.1 (CICE) dated [DATE], the CICE indicated, Resident 1 was identified to have Skin wound or ulcer. The CICE indicated, Resident has c/o [complaint of] pain and discomfort. The CICE indicated Resident 1 ' s skin changes were in Site 43. Right lower leg (rear), and Description: wound and redness on R [right] -leg (rear). Resident 1 ' s skin wound or ulcer was not measured in length, width, and depth, and there was no description of the underlying tissue of the wound. During a review of Resident 1 ' s Physician Progress Notes (PPN) dated [DATE], indicated Staff reported wound on rt [right] leg at lower end of knee immobilizer . Plan- hold d/c [discharge] until wound healing . Visit Diagnoses Primary: Pressure Ulcer, Unspecified site and stage. During an interview on [DATE] at 2:22 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when Resident 1 ' s pressure ulcer was discovered on [DATE], there was no wound measurement done. LVN 1 stated Resident 1 ' s physician was visiting the facility, and they took a picture of the wound. LVN 1 stated that on [DATE], physician ordered a treatment with Medi honey with calcium alginate (dressing used for moderate to heavy oozing wounds and to cover a shallow or fill a deep wound) indicating the pressure ulcer had slough (dead tissue usually yellow, tan, gray, or green in color, usually moist and stingy in texture). During a concurrent interview and record review on [DATE] at 9:49 a.m., with Director of Nursing (DON), DON stated Resident 1 was admitted with right leg immobilizer. DON reviewed Resident 1 ' s clinical record for skin monitoring on the right leg underneath the immobilizer. DON was unable to show that Resident 1 ' s right leg skin underneath the immobilizer was being checked. DON stated the Resident 1 ' s skin should have been checked at least once every shift. During an interview on [DATE] at 12:35 p.m., with Registered Nurse (RN) 1, RN 1 stated if Resident 1 ' s skin was checked underneath the immobilizer, it would be documented in the treatment administration record (TAR). During a concurrent interview and record review on [DATE] at 10:21 a.m., with DON, DON provided Resident 1 ' s Order Recap Report for the month of [DATE]. DON stated there was an order to check to check the skin on Resident 1 ' s right leg. The physicians order dated [DATE], indicated monitor the skin under brace to right leg daily, notify MD [Medical Doctor] if any changes of condition. every day shift. During a concurrent interview and record review on [DATE] at 12:50 p.m., with DON, DON presented Resident 1 ' s Skin Monitoring Comprehensive CNA Shower Review for the following dates [DATE], [DATE], and [DATE]. DON stated after the CNA provided Resident 1 ' s bed bath, CNA would provide the forms to the licensed nurse to sign acknowledging it with a counter signature. The skin monitoring form shower review forms revealed Resident 1 ' s skin underneath the immobilizer on the right leg were not checked. During an interview on [DATE] at 12:18 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated only the licensed nurses would check the resident ' s skin under the immobilizer. During a review of Resident 1 ' s clinical record titled Interdisciplinary Care Conference - V 5 (IDCC) dated [DATE], IDCC indicated a Care Conference for Skin Alteration, for a Trauma - device acquired injury, located at Resident 1 ' s right shin, the measurement for length, width, and depth were blank, and the comment indicated IHA, (In house acquired). The ordered treatment was right lower shin posterior device related pressure injury: cleanse with NS, pat dry apply iodosorb cream and cover with border foam dressing daily, (NS - normal saline; Iodosord - medication used treat wet pressure ulcers and wounds). During a concurrent interview and record review on [DATE] at 10:40 a.m., with DON, DON reviewed Resident 1 ' s Interdisciplinary Care Conference - V 5 (IDCC) dated [DATE], IDCC indicated a Care Conference for Skin Alteration, a wound type was Trauma - device acquired injury, located at Resident 1 ' s right shin, with length in centimeter (cm) 10 cm, width 3 cm, and depth was left blank, and a comment indicated IHA. DON stated Resident 1 ' s pressure ulcer measurement was done on [DATE], and there was no measurement done when pressure ulcer was identified on [DATE]. DON stated the pressure ulcer was IHA. During a review of Resident 1 ' s clinical record dated [DATE], the Physician Progress Notes (PPN), indicated Add cefadroxil bid [two times a day] for 1wk [week] for possible cellulitis (bacterial skin infection) around wound-no fever, ., (Cefadroxil - mediation used to treat bacterial infection). Primary visit diagnoses: Pressure ulcer, unspecified site and stage. Resident 1 ' s PPN dated [DATE] indicated D/w [Discussed with] wound nurse, pt [patient] may need surgical debridement (medical procedure to remove the dead or infected tissue), by surgeon or ortho [orthopedic doctor] given proximity to tendon. Dtr [Daughter] was notified that wound healing may take few wks [weeks]. Resident 1 ' s PPN dated [DATE], indicated, Had lengthy discussion with dtr [Daughter] last week, dtr [Daughter] was concerned about avoidable decub [decubitus/pressure ulcer], pt ' s [patient ' s] lack of socialization and motivation etc, worry if pt [patient] giving up. Size of decub [decubitus/pressure ulcer] getting smaller, slough getting softer too. During a review of Resident 1 ' s clinical record titled Skilled Nursing Facility Discharge Summary SNFDS dated [DATE], SNFDS indicated Resident 1 ' s Date of Discharge was [DATE] with diagnoses that included rt [Right] femur fracture, and rt [right] calf decub [decubitus/pressure ulcer]. During an interview on [DATE] at 1:27 p.m., with Resident 1 ' Responsible Party (RP), RP stated prior to Resident 1 falling, she used to live in an assisted living facility, in her own apartment. Resident 1 could inject herself insulin on her stomach after the staff prepared the insulin. Resident 1 could walk to and from the dining hall with the use of front wheeled walker. RP stated Resident 1 could have a conversation. RP stated currently, Resident 1 not very verbal and she could only respond in a Yes or No answer on somedays. RP stated Resident 1 was discharge on [DATE], with hospice (specialized care that support a person nearing the end of life) care. During a review of the facility ' s policy and procedure (P&P) titled Skin Integrity Management with effective date of [DATE], the P&P indicated The implementation of an individual patient ' s skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed . 2.1 Complete risk evaluation on admission/re-admission, weekly for the first month, quarterly, and with significant change in condition. 3. Identify patient ' s skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. 3.1 Perform skin inspection on admission/re-admission and weekly. Document on Treatment Administration Record (TAR) or in Point Click Care [electronic health records] (PCC). 3.2 Perform wound observations and measurements upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 was administered buspirone (treats anxiety) with adequate monitoring of adverse effects from the medication. This failure had the potential to result in delayed management of adverse effects and unnecessary use of medication. Findings: Review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder (excessive and overwhelming worry about ordinary issues like work, money and family) and anoxic brain damage (brain is deprived of oxygen, symptoms include changes in sleep pattern, trouble speaking and swallowing). Review of Resident 1's Order Summary Report for September 2022 indicated an order for Resident 1 to receive buspirone 5 milligrams via PEG (percutaneous endoscopic gastrostomy, a flexible tube is placed through the abdominal wall into the stomach to receive nutrition and/or medication) two times daily for agitation, restlessness and falling tendency. During a concurrent interview and review of Medication Administration Record (MAR) for August 2022 with Assistant Director of Nursing (ADON) on 7/25/23 at 11:59 a.m., ADON stated, Resident 1's MAR indicated monitoring for antipsychotic (medication that treats psychosis, a severe mental illness) adverse effects was done. ADON stated, Resident 1 was given buspirone, which was an anti anxiety and not an antipsychotic, and had different adverse effects. Review of Resident 1's Medication Administration Record (MAR) for September 2022 indicated Resident 1 was monitored for the presence of tardive dyskinesia (facial tongue movement), cognitive impairment (decreased mental status), akathisia (inability to sit still), parkinsonism (tremors, rigidity, drooling). According to Dailymed, a nationally-recognized publication of the National Institute of Health in the U.S. National Library of Medicine and includes references to drug information submitted to the Food and Drug Administration, buspirone adverse events include; dizziness, insomnia, nervousness, drowsiness, lightheadedness, nausea, headache and fatigue. Review of the facility's policy and procedure titled Psychotropic Medication Management last revised 10/24/17 indicated, Medication effects will be monitored and documented on the medication administration record, to include target behavior monitoring, and monitoring for adverse effects when the medications are used.

Based on observation and interview, the facility failed to ensure dietary services followed proper sanitation for food service safety when: the three compartment sink was not maintained clean. This failure had the potential to cause cross contamination and an outbreak of food borne illness to 98 residents who received food from the kitchen. Findings: During a concurrent observation and interview, in the initial tour of the kitchen, on 5/15/23, at 10:03 a.m., with Dietary Supervisor (DS), observed the three compartment sink right counter with a green worn out sponge and a silvery mesh, a red bucket, an open box of traditional bakery cornbread mix, and surface of the counter was wet and dirty with brownish black and white food particles. The DS stated, they used the compartment sink for manual washing of dishes and pans and were currently using the dish machine. During a concurent observation and interview in a follow-up tour of the kitchen, on 5/17/23, at 10:17 a.m., there was a white residue on the side of the middle sink of the three compartment sink and vegetable food particles in the sink drain. On the side of the first sink was white food residue on the side, and a dirty green sponge with food particles on it, on top of the divider between the middle and first sink. The DS confirmed the three compartment sink was dirty, and will find out the staff who used it. During another interview, in the kitchen, on 5/17/23, at around 1 p.m., the DS agreed that it was not okay that the compartment sink was dirty earlier. DS stated, staff was supposed to be using the dish machine. According to the Federal Food Code (2022), Warewashing Equipment, Cleaning Frequency. A Wareashing machine; the compartments of sinks, basins, or other receptacles used for washing and rinsing equipment, utensils, or raw foods, or laundering wiping cloths; . shall be cleaned: (A) Before use; (B) Throughout the day at a frequency necessary to prevent recontamination of equipment and utensils and to ensure that the equipment performs its intended function; and (C) If used, at least every 24 hours . Warewashing Sinks, Use Limitation. If the wash sink is used for functions other than warewashing, such as washing wiping cloths or washing and thawing foods, contamination of equipment and utensils could occur.

Based on interview and record review, the facility failed to ensure dialysis (a treatment to remove extra fluid and waste products from the blood when the kidneys cannot) communication records were completed for three residents (Resident 201, Resident 54, and Resident 56) out of 5 sampled residents. This failure has the potential to miss signs of illness such as fever or bleeding, which could lead to hospitalization . Findings: A review of Resident 201's admission record indicated admitted [DATE] with a diagnosis of end stage renal disease (the last stage of long-term kidney disease where the kidneys no longer work), with a dependence on renal dialysis. A review of Resident 54's admission record indicated an admitted [DATE] with a diagnosis of end stage renal disease with a dependence on renal dialysis. A review of Resident 56's admission record indicated an admitted [DATE] with a diagnosis of hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease and dependence on renal dialysis. During a record review of Resident 201's Order Summary Report, dated 5/18/23, Order Summary Report indicated, Resident 201 was to have dialysis three times a week on Tuesdays, Thursdays, and Saturdays. During a record review of Resident 54's Dialysis Communication Record, dated 4/22/23, the Dialysis Communication Record section Post Hemodialysis Assessment indicated, blank areas as well as section labeled Graft Assessment. During a record review of Resident 56's Dialysis Communication Records, dated from 2/10/23 until 4/24/23, the Dialysis Communication Records indicated missing information for post-hemodialysis assessment section in the dialysis records dated 2/10/23, 2/22/23, 3/24/23, 4/10/23, and 4/24/23. During a concurrent interview and record review of Resident 201's Dialysis Communication Records, dated 5/16/23 and 5/17/23, with Registered Nurse (RN 1), RN 1 confirmed the Dialysis Communication Records had missing information in the pre-hemodialysis assessment on 5/16/23, and post-hemodialysis assessment on 5/17/23. RN 1 stated it was important to assess the resident prior to and after coming back from the dialysis center. He stated there needs to be communication with the dialysis center if there are any changes in the resident such as infection, illness. RN 1 further stated it is important to monitor the resident for any bleeding from the dialysis access site since that would be an emergent situation. During a review of the facility's policy and procedure titled, Dialysis, Coordination of Care & Assessment of Resident, dated 1/2018, policy indicated, 2. While at the skilled facility: This facility as direct responsibility for .the customary standard care provided by the facility and the following: [ .] 2. Monitoring of vital signs post dialysis or per physicians order

Based on observation, interview, and record review, the facility failed to ensure medication error rate of less than 5% when three errors were observed in 36 medication pass opportunities which resulted in 8.33 % medication error rate. The errors as follows: Dorzolamide HCl solution 2%, (used to lower high eye pressure), Fish Oil capsule (Omega -3 Fatty acids- supplements) and Multivitamin with minerals medications were omitted for Resident 43, during medication pass observation on 5/16/23. This failure had the potential to put resident (Resident 43) at risk for harm and/or adverse consequences. Findings: During medication pass observation and concurrent interview with LVN 1 on 5/16/23, at the beginning of 8:50 AM, at the doorway of Resident 43's room, Licensed Vocational Nurse (LVN) 1 was preparing Resident 43's medications with gloves on. LN 1 was observed administering the following medications via G-tube (Gastrostomy tube- a tube inserted through the wall of the abdomen directly into the stomach) to Resident 43: Amiodarone HCL (anti arrhythmic-a type of drug that is used to help the heart stay in a normal rhythm)50 mg (milligram, a unit of measurement) 1/2 tablet, Vitamin C 500 mg, Keppra (antiepileptics- a type of drug that is used to prevent or treat seizures) 500 mg one tablet, Senna (Laxative) 8.6 mg 2 tablets. LVN 1 crushed the medication individually and put in an individual medication cup. LVN 1 diluted each crushed medication with 20 cc to 30 cc (cubic centimeter- measure of volume in the metric system) of water in each cup. After the prepared medications were administered to Resident 43, LVN 1 washed her hands and stated she was done giving resident 43's medications and asked the resident if he preferred yoghurt to eat. During Medication Reconciliation (the process of comparing a patient's medication orders to all the medications that the patient has been taking to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions) on 5/16/23 at 10:30 AM, with the Director of Nursing (DON), Resident 43's Medication Administration Record (MAR) dated 5/16/23 was reviewed. The MAR indicated the Domazoline eye drops, Multivitamin with minerals and Fish oil 1 capsule 1000 mg were documented as being administered during the medication pass observed on 5/16/23 at 8:50 AM, in addition to the medications listed above. During an interview with the Director of Nursing (DON) on 5/17//23 at 10:30 AM, the DON stated, her expectations for the nurses during medications administration via G-tube included ensuring the right medication, correct dosage, administered at the right time, the right route and right resident. The DON stated the nurses should be giving the medication as ordered. She added LVN 1 was given an Inservice regarding medication pass and will follow it up. During a review of the facility's policy and procedure titled SPECIFIC MEDICATION ADMINISTRATION PROCEDURES dated 4/2008, indicated 11B1 PROCEDURE FOR ALL MEDICATIONS To administer medications in a safe and effective manner. There was no information indicated for omitted medications.

Based on observation, interview and record review, the facility failed to develop a baseline care plan for one of six residents (Resident 351) within 48 hours of admission to the facility. This failure ha the potential to not providing an effective, person-centered and quality resident care. Findings: Resident 351 is a [AGE] year old, admitted [DATE], with diagnoses including Hypertension (high blood pressure), difficulty in walking and hyperlipidemia (cholesterol in the blood), Hemodialysis(treatment of filtering waste and water from your Blood). During the initial facility tour on 5/15/23 at 10:30 am, observed Resident 351 in bed with Oxygen at 2L/min, lying on a low air loss bed, turned to her left side facing the glass sliding door. A follow up visit with Resident 351, on 5/17/23, at 10:05 am, observed resident in bed turned to left side facing the glass sliding door. Resident 351 said ouch when surveyor introduced self to resident. Did not verbalize any words or response to questions asked by surveyor. During an interview with AD, on 5/17/23, at 11 am, AD stated, no assessment done yet, resident was only admitted last Sunday 5/14/23. During a review of the 20 pages document titled Initial Baseline Care Plan dated 5/14/23, the document did not indicate initial goals, ADL (activities of daily living) needs/goals, nutritional needs/goals, special treatments and procedures, bowel and bladder, skin integrity concerns, medical diagnosis requiring care, physician's orders, medication, discharge planning, any interdisciplinary team members contribution, any family contribution. During an interview with the DON, on 5/18/23, at 11:21 am, the DON stated, the baseline care plan was not completed within 48 hours of admission. DON further stated, the SSA just called the family to schedule conference and discuss the baseline care plan. During a review of the facilty policy and procedure (P&P), titled Baseline and Comprehensive, dated 11/2017, the P&P indicated, .policy of this facilty to develop upon admission .an interim .care plan for the resident .(1) A baseline care plan will be implemented within 48 hours of admission. (2) Addresses immediate resident's need .(3)Will provide the residents and representative with a written summary of the baseline care plan .

Based on observation, interview and record review, the facility failed to review and revise a comprehensive plan of care for one of six residents, (Resident 27), when her wounds were healed and wanted to get out of bed and do more things outside the facility. This failure had the potential for Resident 27 to cause further decline of mobility and psychosocial issues. Findings: Resident 27 is a [AGE] year-old female admitted in December 2021 with diagnoses including protein-calorie malnutrition; type 2 diabetes mellitus (blood sugar disorder) and contracture (shortening or stiffening) of muscles. The minimum data set (MDS- assessment tool), brief interview for mental status (BIMS), dated 12/14/22, score 13, indicating intact cognition. During the initial tour of the facility, on 5/15/23 at 10:38 am, observed Resident 27 lying in bed. A follow up visit with Resident 27 on 5/17/23, at 11 am, observed Resident 27 is still in bed. When asked if she had been getting up, she stated ,I do not get up at all . I had a lot of sores but now I'm better .I want a mobile wheelchair to get around. When asked about discussing her concerns with anyone in the facility, Resident 27 stated, I have not seen a social worker. I have not attended any meeting or care conference to discuss my care .I want to talk to my doctor to know more about my condition .I had blood test done but no one had discussed results with me .I requested a copy of my records couple of months back when I was at the other hall but have not received it yet .I asked again for a copy of my record but had not gotten it yet .I really want to know about my care .I want to be prepared to go and live outside but I do not know how to go about .I heard from someone who is now in an assisted living that I can be evaluated and be referred to some services . During a record review of the Multidisciplinary Care Conference 1 Notes, dated 6/29/22, the note indicated, social worker and activity department in attendance and did not indicate resident participation. During an interview with SSA and SSD, on 5/17/23, at 1:44 pm, SSA stated, he had just started two months ago, he sets up care conferences now, following the MDS schedule and had not receive any information of pending ancillary referrals nor any social service needs of residents. The SSD who was present during the interview stated, he just started last Wednesday. During a review of the active Order Summary Report, dated 5/18/23, the Order Summary Report indicated, out of bed for meals-upright in chair for eating with meals. During a review of the Policy and Procedure (P&P) titled Care Plan Goals and Objectives, dated 11/2012, the P&P indicated, .will incorporate goals and objectives .1(a) Resident oriented .(2) .reviewed by all staff involved .(3) .reviewed and revised .(c) .quarterly. During a review of the Policy and Procedure (P&P), titled Care Plan Comprehensive, dated 8/25/21, the P&P indicated, the facility's interdisciplinary team, in coordination with resident and his or her family must develop and implement a comprehensive person-centered care plan for each resident .

Based on observation, interview, record review, the facility failed to ensure one of 21 sampled residents (Resident 251), had clean and groomed fingernails. This failure had the potential to cause Resident 251 pain, injury, and infection. Finding: During a concurrent observation and interview on 5/16/23, at 10:04 a.m., Resident 251's fingernails were long, and dirty with black matter inside the nails. Resident stated,, they told staff about it and staff didn't do anything about it. Resident 251 stated it was upsetting. During a concurrent observation and interview on 5/17/23, at 1:02 p.m., with Director of Nursing (DON), Resident 251's fingernails were observed. DON stated Resident's 251's fingernails were long and dirty. During an interview on 5/17/23, at 1:25 p.m., with licensed vocational nurse (LVN) 3, LVN 3 stated Resident 251's long and dirty fingernails should have been identified on admission and were a risk for infection. During an interview on 5/18/23, at 11:01 a.m., with CNA 1, CNA 1 stated, they cleaned and cut Resident 251's fingernails on 5/17/23. CNA 1 stated, CNAs should have checked Resident fingernails every day and notified the nurse if they were long and dirty. CNA 1 stated, Resident 251's fingernails were missed and should have been checked and cleaned earlier. During a review of Resident 251's Order Summary dated 5/18/23, the Order Summary indicated Resident 251 was admitted on [DATE]. During a review of Resident 251's Brief Interview for Mental Status (BIMS, a screening tool used to assess cognition), dated 5/8/23, the BIMS indicated Resident 251 had intact cognition. During a review of the facility's policy and procedure (P&P) titled, Fingernail/ Toenails, Care of, Revised 2012, the P&P indicated, .nails are clean and trimmed regularly .

Based on observation, interview, and record review, for one of three sampled residents (Resident 15), the facility failed to document an adequate indication and diagnosis for the use of Seroquel (a medication used to treat certain mental/mood condition). This failure placed Resident at unnecessary risk for adverse consequences related to the use of Seroquel. Findings: During a review of Resident's 15 face sheet, the face sheet indicated Resident 15 was admitted on [DATE] (originally admitted on [DATE]), with diagnoses that included Alzheimer's disease [a degenerative disease and is the most common cause of dementia (gradual loss of memory and decision-making capacity)]. During a review of Resident 15's Minimum Data Set (MDS- an assessment tool used to direct resident care dated 4/20/23 indicated a brief interview for mental status (BIMS, a brief scanner to help detect cognitive impairment) indicated score of 01 indicating Resident 15 had severe cognitive impairment. During a review of the physician order dated 5/18/23 had a Seroquel order (dated 11/1/21) 25 milligrams (mg) Give 3 tablet by mouth two times a day m/b people are stealing her belongings related to Psychotic disorder with delusions due to known physiological condition. Also had a Lorazepam order (dated 4/11/21) 1 mg Give 1 tablet by mouth two times a day for m/b physical and verbal aggression related to anxiety disorder. During a review of MDS for Resident 15's active diagnoses, the MDS indicated diagnoses that included Anxiety disorder, Manic depression (bipolar disease), Psychotic disorder (other than Schizophrenia), Alzheimer's disease. During a review of Resident's 15 care plan for Seroquel medication, the revised care plan dated 3/8/23 indicated Box warning for use of Seroquel - Seroquel (quetiapine) is not approved for the treatment of patients with Dementia-related psychosis and care plan dated 4/29/21 indicated Geriatric use: increased mortality in elderly patients with Dementia-related psychosis. During an interview with Assistant Director of Nursing (ADON) on 5/17/23, around 8:30 am, ADON indicated, Resident was taking Seroquel for psychotic disorder. ADON stated, she was unable to find any history of mental illness (before admission) for Resident 15. During a review of the Level 1 Pre-Admission Screening and Resident Review (PASRR - a tool that helps identify possible serious mental illness or related conditions) dated 1/23/20, indicated Resident had no diagnosis of mental disorder such as Schizophrenia/Schizoaffective Disorder, Psychotic/Psychosis, Delusional, Depression, Mood disorder, Bipolar, or Panic/Anxiety. During a review of Resident 15's Medication Administration record/behavior data for Seroquel. ADON did not provide one for the month of April 2023 as requested. Review of the behavior data dated 3/1 to 3/31 2023, 5/1 to 5/16 2023, indicated zero (0) number of behavior episodes per shift. During a review of the Medication Regimen Review (MRR) done by the pharmacy consultant, for March and April 2023. The MRR for March 2023 indicated no recommendations. The MRR for April 2023 dated 4/19/23, indicated, Psych Referral to CHE Behavioral Health Services recommended at this time. During an interview with ADON on 5/17/23 at around 2:20 pm and 5/18/23, at 8:20 am, ADON stated Pharmacy consultant's recommendation dated 4/19/23 has not been acted upon due to the transition of the facility to a new owner and they would be acting now. ADON verified that she was aware of the box warning (a type of warning that appears on the package insert for certain prescription drugs) of Seroquel for Resident 15 in Resident's care plan, and they were monitoring Resident for side effects. During an interview with ADON on 5/18/23, at 1:22 pm, ADON stated, she was unaware that the there was misdiagnosis of Resident 15's indication for Seroquel. According to the manufacturer, Seroquel is not approved for the treatment of patients with dementia-related psychosis (Reference www.nih.gov)

Based on observation, interview, and record review, the facility failed to obtain a physician's order for oxygen administration for one of four sampled residents (Resident 150). This failure had the potential to place Resident 150 at risk for incorrect oxygen treatments and jeopardize Resident 150's health and wellbeing. Findings: Resident 150 was admitted to the facility on [DATE] with admitting diagnoses that included weakness and lack of coordination. During an observation on 5/15/23, at 11 am, Resident 150 was observed sitting in a chair by her bedside, with oxygen (O2) via nasal cannula (a two-pronged plastic tubing used to deliver oxygen therapy through the nose), attached through the long tubing to the oxygen concentrator ((a medical device for oxygen therapy, it takes in air from the room and filter out nitrogen). Resident 150's O2 was observed at 2 Liters per minute (L/min). During an observation on 5/17/23, at 11:05 am, Resident 150 was observed sitting in her wheelchair. Resident was waiting for the physical therapist per family. Resident with oxygen nasal cannula on but tubing not attached to the oxygen concentrator set at O2 1 liter. When asked, Resident stated she was currently having a little shortness of breath. During a concurrent record review and interview with Licensed vocational nurse LVN 3 stated, Resident 150 is on O2 at 2L and believe there is a doctor's order. LVN 3 searched for the physician order for oxygen for Resident 150 in the electronic health record but could not find it. LVN 3 stated, I don't see any order for oxygen in electronic and would verify in hard chart. She looked in the hard paper chart for the physician order for O2 and could not find it. LVN acknowledged there was no physician order for oxygen. During a review of the facility's policy and procedure (P & P) titled, Nursing Policies and Procedures Manual. Dated November 2012, the P & P indicated OXYGEN . Procedures for Documentation: Obtain or verify physician's order .a. mode of delivery b. Liter flow rate. C. Duration of therapy, i.e., continuous, prn shortness of breath, or .as specified by the physician.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was not left alone while standing to prevent a fall from occurring when Certified Nursing Assistant (CNA) 1 left Resident 1 unattended in his bathroom to retrieve his wheelchair from his room. This failure resulted in Resident 1 falling off the shower chair and sustained several injuries that included facial fractures (broken bones), and a spinal injury. Findings: A review of the admission record for Resident 1 indicated he was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident 1's Admission Minimum Data Set (MDS-an assessment tool) dated 2/2/19 showed Resident 1 had a history of [REDACTED]. The MDS also showed Resident 1 required extensive assistance (staff needed to provide weight-bearing support) and one person physical assist during transfers from chair to wheelchair or bed, walking in room and toilet use. A review of the Fall Risk assessment dated [DATE] indicated Resident 1 scored 20, which placed him in the high risk category for falls. During an interview on 2/28/19 at 10:25 a.m. in Resident 1's room, CNA 1 stated on the morning of 2/12/19 Resident 1 was seated on a shower chair in his bathroom over the toilet. CNA 1 stated she told Resident 1 to wait there. CNA 1 described how she went out of the bathroom briefly to retrieve Resident 1's wheelchair, which was in Resident 1's room near the entrance door to his room. CNA 1 stated she heard a loud thud, and she ran into the bathroom and found Resident 1 face down on the floor. CNA 1 stated, it happened so quick, and that there were no witnesses to the fall. CNA 1 stated she had to take her eyes off of Resident 1 to go retrieve his wheelchair out of Resident 1's room to bring it into the bathroom, and that she could not see Resident 1 while she did that. A review of Resident 1's care plan initiated on 1/26/19 indicated, The resident is high risk for falls related to gait/balance problems . Interventions include, Do not leave patient unattended .Remind staff not to leave resident unattended when doing activities of daily living (ADL's). Review of the Change of Condition Evaluation form dated 2/12/19 at 4:11 p.m., showed Resident 1 had a witnessed fall in the bathroom. Resident 1 obtained a forehead injury and was sent to the hospital. Review of the ED (Emergency Department) Physician Notes dated 2/12/19 indicated Resident 1 was noted with approximately four centimeters of laceration over the left eyebrow and [MEDICAL CONDITION] eye socket bone, broken swollen and bloody nose. Further review of the notes indicated Resident 1 obtained a neck injury with widening between cervical spine number 5 and 6 vertebrae (small bones that form the spine). A review of the facility's undated Falls Prevention Strategies and Interventions list, showed interventions that included: Adequate staff supervision and keeping resident in sight or close by for interaction.